Can The AAOS And Its Compliance Program Do More?

The Disruptive and Impaired Physician

Edward V. Craig MD, MPH

AAOS Judiciary Committee

Symposium: Disruptive and Impaired Physician

Edward V. Craig MD, MPH

I have no potential conflict with this presentation

AAOS Compliance Program And Standards Of Professionalism

Background: How We Got Here

Where Did The Standards (SOP) Come From?

• For Years– AAOS Heard From Members

• Through Professional Liability Committee

• Need to Address Fraudulent and Misleading Testimony

• Fellow Support---Sanction Based Program

Background---2002

• BOC—Advisory Opinion To AAOS Board

• Resolution—Florida Orthopaedic Society

• Need----Professional Conduct Program Regarding Expert Witness Testimony

Background --2005

• AAOS Bylaws Established Professional Compliance Program

• Appointed Committee on Professionalism (COP) and Judiciary Committee To Resolve Disputes ----The Grievance Process

• Standards Of Professionalism (SOP)—First Three Approved

Standards of Professionalism

• Based Upon AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons

First Three Standards

• Musculoskeletal Services To Patients

• Professional Relationships

• Expert Witness Testimony

Additional SOPs Adopted

• 2006 – Research and Academic Responsibilities

• 2007Advertising by Orthopaedic Surgeons

• 2007Orthopaedic Surgeon-Industry Conflicts of Interest

Grievance Process

• One AAOS Fellow Can File Grievance Against Another

• Violation Of Any Standards

• Multilevel Process---Culminate AAOS Board

Allocation of Board Time---Program

. Program Operating Expenses

• Professional Compliance Program Budget includes: – 2011 budget - $1M for litigation expenses– Initial proposed 2012 budget

$1M for litigation expenses

Program: Time Consuming and Expensive

Official Disciplinary Actions Reported To:• National Practitioner Data Bank

(Suspensions and Expulsions Only)• State Licensing Boards• ABOS • State Medical Societies

and Associations

Grievance Process--Sanction Based Program

Professional Compliance Program

….and Reported to Fellowship:

Judiciary-Non SOP :Loss Of Medical License by Fellows

• AAOS Surveillance System• Fellow—Need To Have License

Unencumbered, No Restrictions ( State Action: Impairments- Drugs, Alcohol)

• Any State Disciplinary Action—Considered A Restriction, Subject to Compliance Action—Including For Disruptive Behavior

• Usually Suspension

Medical License Loss- Substance Abuse

• Most Difficult For Judiciary---Illness, Volitional, in Treatment or Not, Complying With Aftercare, etc.

• Each State has Differing Response--- Judiciary Can Consider

Extent Of The Problem—Among Physicians

• 8-12% Will Develop Substance Abuse Problem at Some Point Career

• At Any Given Time Up To 1 in 20 (3%- 7%) are Active Substance Abusers

• Left Untreated 17% Mortality Rate

Independent—Age Range,Geography

Urban/Rural

Incidence By Medical Specialty

• No Specialty Immune

• Emergency Medicine, Psychiatry, Anesthesiology Slightly Higher Incidence—

Archives of Surgery (2012)—Survey 27,000

• 15.4% had a Score on Alcohol Abuse Identification Test ( Abuse or Dependence)

• Correlation –Alcohol Abuse or Dependence– Major Medical Error Prior 3 Months– Surgeons Who Were Burned Out– Surgeons Depressed– Emotional Exhaustion

• Having Children, Working for VA—Lower Likelihood

Risk factors

• Parallel General Public–Strong Familial Association–Psychological or Psychiatric Disorders

• Unique to Physicians–Self Treatment with Prescription Meds–High Stress or Long Hours–Access to Controlled Substances

Cicadas—Substance Abuse Among Physicians

Hospital Medicine, 2003

Other Risk Factors

• Smoking One or More Packs/day• Multiple Affairs or Marriages• History Multiple Jobs in Multiple

Communities• Academic Medicine

Cicadas—Substance Abuse Among PhysiciansHospital Medicine, 2003

Archives of Surgery- 2012• Alcohol Abuse and

Dependence “ a Significant Problem”

• Suggested Organizations-ACS, AAOS Develop Early Warning and Intervention Programs

Are We Doing Enough?

• If Statistics Correct---

In USA: 2,500-3,700– Current Orthopaedic Surgeons will Develop Alcohol or Substance Abuse Problems—At Some Point in Career

Physician Health Programs ( PHP)

• Most States Have—Identification, Treatment , Support—Non Disciplinary

• Confidentially: Deal With Abuse Issues

• 17% Orthopaedic Surgeons Practice in States That do not Have PHP ( 5,308 surgeons)

Consequences—Depend On State Where Fellow Practices

• PHP states—often not come to state licensing board ( Confidential-Treatment)

• Non PHP States– state licensing board, discipline, license loss, public disclosure, AAOS Compliance

• Potential exists for groups to be treated differently by AAOS

Judiciary Committee Actions• Disciplinary Action- Guiding Principles

and Special Considerations

• Generally Not “Second Guess” State Licensing Boards

• Special Cosiderations- No Compliance Action Pending Treatment Program—Therefore Not Reported

Should AAOS Do More ?

• Recognize Widespread Nature—

• More Publicly Acknowledge and Discuss

• Education—Fellows, Residents

AAOS---Education on SOP

• Annual Meeting- ICL, Symposia• Publications—AAOS Now, OKU• On Line Module- Requirement For

Membership• Module—Residency Training

Disruptive Physician Behavior

• Medical errors• Adverse

outcomes• Cost• Personnel Loss• Litigation

Orthopaedics—4th Highest Field Prevalence

Problems

• AMA—established definition Disruptive Behavior

• Surgeons—Disagree What Disruptive Behavior is in Practice ( Interpretation)

• Survey 110 Surgeons– 9 behaviors disruptive by national organization– 4 classified as disruptive by surgeons

JBJS 93 A Orthopaedic Forum, 2011

Does Compliance Program Deal With Disruptive Physician?

• State Licensing Surveillance: Disciplinary Action—Disruptive

• S.O.P.--Professional Relationships

• S.O.P.--Musculoskeletal Services To Patients

One Fellow Must Bring Complaint Against Another

Potential Problems—The Slippery Slope

• Hospital By Laws—Code of Conduct• Complaints– Peer Review Process• Potential ” Sham Peer Review”• “Disruptive Physician” Code Word—

Vendetta, Competition— Potential Weapon• State—Disciplinary Action—NPDB, AAOS

considers License restricted

Aggressive Anger Outbursts

Profane/Disrespectful Language

Throwing Objects

Demeaning Behavior

Physical Aggression

Sexual Comments or Harassment

Racial/Ethnic Jokes

PassiveAggressive

Derogatory comments about

institution, hospital, group, etc.

Refusing to do tasks

Passive

Chronically late

Not responding to call

Inappropriate or inadequate chart

notes

Spectrum of Disruptive Behaviors

FSPHP April 23-26, 2012

Williams BW, Swiggart WH, Ghulyan MA, Vickers, K, Williams MV

33

AAOS—Documents Limited Disruptive and Impaired

• Acknowledge Issues

–Code of Medical Ethics

–Standards Of Professionalism»Musculoskeletal Services»Professional Relationships

AAOS--Comprehensive Position Statement( Disruptive Physician Behavior)

• Defining Disruptive Physician Behavior• Facilitate Reporting Protocol• Ensure Fair Evaluation and

Management

Standard— Medical Centers—Increase Patient SafetyJBJS 93 A Orthopaedic Forum, 2011

Summary

• PCP is An Ethics Compliance Program• SOP’s Define Levels of Acceptable

Conduct• What To Do With Impaired and

Disruptive Physician Issues ?• Goal – Achieve/Maintain a High Level

of Professional Behavior by AAOS Members---How? Role of Education?

Thank You

• Rick Peterson--AAOS• Melissa Young--AAOS• Murray Goodman—Chair, COP• Richard Schmidt—Chair, Judiciary• Michael Parks—Past AAOS Board